Perry Wilson, MD, discusses the new quackery with Steven Novella, MD

Steven Novella, MD, is a faculty member at Yale School of Medicine, a practicing neurologist, and the host of the wildly popular podcast "The Skeptics' Guide to the Universe," where he and his group of "skeptical rogues" discuss scientific topics with an eye on calling out flim-flam and hokum.

As a physician, Novella has spoken out against homeopathy, acupuncture, and other alternative medicine modalities, based on a lack of robust evidentiary support or prior plausibility.

I had the chance to speak with Novella in the studios at Yale. We discussed a wide variety of topics ranging from the public's view of science and scientists, to interacting with patients who hold nonscientific beliefs.

Our full interview appears here.

Perry Wilson, MD: I'm joined today by Dr. Steven Novella. Dr. Novella is a faculty neurologist here at the Yale School of Medicine, but he's perhaps best known as the host of "Skeptics Guide to the Universe," one of the, if not, most popular science podcasts out there right now. Steve, thanks so much for joining me on Doc to Doc.

Steven Novella, MD: Thanks for having me. It's a lot of fun.

Wilson: Now you're the editor of a blog called Science-Based Medicine. I wanted to start there. What is science-based medicine? How's that different than evidence-based medicine, which we've all been told we need to practice?

Novella: Yeah. Yeah, that's a great question. I mean, obviously evidence-based medicine is fantastic. It's good. As we say, it's good as far as it goes, but it doesn't go far enough and it gets a couple of things, I think, importantly wrong. I think we know a lot in the last 10 or so years when we've looked at the literature, we realized that you can't just look at clinical trials and answer questions about what treatments are likely to work or what the net effect of a medical intervention.

You have to look at all the science. You have to look at prior plausibility as well. In fact, we know now rigorously that you can't really interpret clinical trials unless you know the overall scientific plausibility of the hypothesis that you're testing. So science-based medicine, in short, considers all of the scientific evidence completely and doesn't focus narrowly on just the clinical evidence and throwing out ... in our opinion, they tend to throw out prior plausibility.

For example, like a Cochrane Review will look at a highly implausible therapy with completely mediocre results and say, "Oh, this is interesting and should be studied." It's like no, it's actually not interesting and the evidence is completely consistent with the null hypothesis. And no, it shouldn't be studied any further. It's been studied more than enough to reject this highly implausible hypothesis to begin with. So we come to very different conclusions looking at the same data when you consider all the evidence, versus put blinders on almost deliberately and just focus on clinical trials.

Wilson: So the scientific method here is central, right?

Novella: Of course.

Wilson: We're building upon prior evidence, biological plausibility. In some cases, even chemical or physical plausibility, if you're talking about something like homeopathy for example. In your experience over the past, let's say, 30 years, how's the public's attitude towards science and towards scientists changed? Is it doom and gloom? [laughter]

Novella: It's not doom and gloom. Science and scientists are still highly regarded in society in general. People tend to cherry pick. They tend to choose which science they want to believe. They don't necessarily reject all of science just because there's one piece of it, but I do think that the public has been deliberately confused about what is the consensus of scientific opinion and what qualifies as good science.

There have been deliberate campaigns of doubt and confusion as we say, right? I mean the classic example is, of course, the tobacco industry that did a very good job of sowing doubt and confusion about the health risks of smoking, and that model has just metastasized and now we see it with regard to all sorts of things.

Interesting within medicine, I think the most interesting phenomenon has been the re-branding of what 50 years ago was universally known as health fraud to an alternative to medicine. This is now ... what used to be fraud is now alternative. And in order to make that sale, they, in a large way, turned science on its head. They said, "No, we're going to use science differently. We're going to use different standards of evidence. We're going to use pragmatic studies as if they were efficacy trials, etc. We're going to ignore prior plausibility or scientific plausibility and it's all good. We're going to have this 'western medicine' dichotomy that doesn't really exist and pretend like some things can't be studied, except in the ways we want them to be studied because those are the ones that give the results that we like."

So, it's been an amazing deliberate campaign to confuse how we know stuff in medicine in order to allow in this really low standard of evidence because these are treatments that don't do well when you hold them to rigorous standards.

Wilson: This brings us to our patients. You're a practicing neurologist. You see patients clinically all the time.

Novella: Right.

Wilson: Do you see patients that hold nonscientific beliefs? I assume you must, and how do you interact with them?

Novella: Yeah. Yeah, every day. It's a very, very common occurrence. Patients sometimes just ask, they're curious, "Hey, should I try this? Should I try acupuncture for my migraines? I've heard good things," or they tell me, "Oh, I'm taking this supplement. Is this ... ?" They may just tell it to me asking me about it or they may just be informing me that they're taking this supplement.

In Connecticut, unfortunately, naturopaths are common and a lot of patients will tell me, "Yeah, I saw a naturopath and they prescribed this homeopathic remedy for me." Sometimes a very, very common story that I hear is, "Yeah, I saw two or three physicians. I think I have Lyme disease, and my physicians say I don't have Lyme disease because my tests are negative and I don't meet the criteria," whatever. "But I looked up the symptoms on Google and I have all the symptoms. So then I went to a naturopath and he did a lot of tests on me, and he says I do have Lyme disease, and he gave me this homeopathic remedy for it."

This is unfortunately a common occurrence. Obviously, we have to form a therapeutic relationship with our patients and you can't be judgmental towards them, so it's a very challenging framework in which to confront these issues. But I think a few things. One, if a patient is in my office, they're there to get my professional advice and they are already acknowledging by their very presence that they have some respect for science-based medicine, for evidence-based medicine. I do think that they expect that I'm going to give them my honest opinion, and so I give it. I say, "Listen, I looked at the research on this, and in fact, I do not think that this is a valid treatment. I don't think that this is going to be effective," or "I don't think that you have Lyme disease for these reasons."

They generally appreciate the fact that I took the time to actually look at the literature even though it may be more of a fringe treatment and not something that physicians are giving, and they appreciate that I take the time to explain to them why I feel the way that I do. I don't pull my punches, but I say just very non-judgmentally, "These are the facts. This is my interpretation of the evidence," or "Here's the standard recommendation of the relevant professional society. This is why we think..." You also have to gauge what's the patient really thinking? You can't just lecture them. You have to sort of interact with them. Sometimes they have misconceptions that are pretty easy to fix.

So, it takes ... you have to invest the time to understand the narrative, understand what the patient is thinking, understand what they want, address the information that they're being given. So, yeah, we live in a time where we have to spend a lot of our time, I think, undoing a lot of misinformation that's being fed to our patients, but it's absolutely worth it and the effect could be definitely worth the time that you're investing. Because if you think about it, you could have the best plan for your patient that's all science-based and has class I, double-blind, placebo-controlled clinical trials, but if they don't believe it because they were told something else by their naturopath or whatever, it doesn't matter. You have to get them to buy into how to approach the therapeutic strategy that you're going to be taking.

Patients do share with us. We all want to use what works, right? We want to know what works and what is safe. We all have that same goal and you should have a pretty sophisticated understanding, I think, as a practitioner of how we know what works and how we decide what is above the waterline in terms of using it. You should get the patient to understand that at least ... they're going to buy into your treatment recommendations.

Wilson: How often do you think this is successful? It's not going to always be successful.

Novella: Yeah.

Wilson: How many patients do you think you sit down, you talk to them, say, "You know what? Okay, I'm going to go with [laughter] the treatment that has some science behind it."

Novella: Yeah, yeah. I mean, I don't have numbers for you because you would have to really ... it'd be hard to study that.

Wilson: Yeah.

Novella: But obviously patients don't come back to me. I don't know if they don't come back because they got better or if they didn't come back because they decided they didn't want to do what I said. I can only tell you about the patients who do come back and what happens, and my experience is generally positive, at least, again, with those selective patients. Again, they appreciate the fact that I spent time explaining to them, and you can usually make them understand why at least I have the opinion that I do. And yeah, patients generally listen to what I have to say.

Again, highly selective in terms of who comes to me in the first place and who decides to stick with it. But I mean I've never had a patient get angry with me or storm out, or anything like that. I've never had any of those traumatic negative experiences. And of course, we all struggle with compliance. Again, it's hard often to get patients to do what you need them or want them ...

Wilson: Any patient. [laughter]

Novella: Any patient in any context, it's hard. Compliance is difficult. But it's been successful for me dealing with patients and the feedback has been generally very positive.

Wilson: So a challenge for physicians is when a patient asks you about one of these therapies that you've never heard of.

Novella: Mm-hmm.

Wilson: [laughter] This happens. Okay, I've heard of acupuncture.

Novella: Yeah.

Wilson: I sort of know some literature there. Someone comes in and asks me about reflexology.

Novella: Yeah.

Wilson: Or something that really ... I have not looked into this. What are the resources available to physicians? Because if I Google this, I'm going to get into a world of trouble. So what resources do physicians have to find out what is the evidence, if there is any?

Novella: Yeah.

Wilson: We can do that due diligence because we'd all love to tell our patients, "Yeah, you know what? I read up on this."

Novella: Yeah, yeah. Yeah, that happens a lot too. Patients ask because there's so many things out there, so many specific things. I don't have encyclopedic knowledge of every supplement out there. Patients ask me about things that I am only vaguely familiar with or I just flat out never heard of before. I'll say, "Oh, that's ... I've never heard of that particular treatment before." I might give them some general advice about that type of treatment. I'll say, "I'm usually a little cautious about supplements because the industry isn't very well regulated." So, you can give some general advice, "But I'll look at that specific one for you and let you know what I find." Sometimes you find interesting things, like I've had patients who were taking supplements that had lots of stimulants in them that they weren't aware of and they were getting palpitations and what-not.

So sometimes you can give them very specific, factual information that's helpful. Or you could say, "Listen, it hasn't been studied. We essentially know nothing about this, and this is why I don't recommend you try it for these various reasons." Or maybe it has been studied. Like acupuncture, for example, or lots of homeopathic remedies have been studied. Lots of electrical stimulation have been tried for a lot of different things.

There is often a literature out there on these things, and you can find them in PubMed. You can find... I think I wouldn't shy away from Google. You've just got to know how to search to find the good stuff. Obviously, there are some academic sites and there are some sites like Science-Based Medicine. That's part of what we try to do is just to do thorough evaluations of the more fringe stuff so that when a practitioner does search on something weird, maybe it'll come up on Science-Based Medicine. They'll have at least somebody who looked into it and tried to analyze it from a scientific point of view.

It may take a little bit more legwork to find the information, but it's there. It's often there. You probably should develop the skill and the familiarity to quickly assess it. The good news is there often isn't a thousand studies of these things. Usually, it's like there's five or 10 and you can pretty quickly say, "Oh, good. There's a systematic review and it shows that it doesn't work. Okay, good. I did my due diligence. I know this doesn't work." You're like, "I suspected it didn't because the plausibility is incredibly low."

But again, a little bit of investment goes a long way. Then once you do that on a regular basis, of course, you then become very familiar with all the most common things that patients are going to ask you, so you have to do less and less of it to keep up.

Wilson: Where is the intersection between skepticism and the medical establishment? Where is it now? Where would you like it to be in the next 10, 20 years?

Novella: I think skepticism basically is just rigorously applying critical thinking, meta-cognition, understanding science, and pseudoscience to the kinds of questions that we confront in our everyday lives. Medicine, obviously, and healthcare, in general, is part of that. I think there's no distinction between those things. It's just one aspect of what skepticism is.

In terms of institutionally, it definitely, I think, needs to be integrated a lot more. I mean we're trying to promote that as much as we can through Science-Based Medicine. I think in the U.K. they're a little bit ahead of us in that they actually ... multiple universities have professorships of the public understanding of science and that seems to work really well. I'm not familiar with any such academic positions in the United States, but I'd love to start to see things like that. Universities take very seriously the need to popularize and promote the public understanding of science in general and medicine in particular.

I think if the academic infrastructure isn't going to try to educate our patients just society-wide about the nature of the relationship between science and medicine, then we are going to lose to the people who are trying to miseducate the public about that because they have billions of dollars on the line, right? They have something to sell and it's in their financial interest to misinform patients about the nature of placebo, the nature of evidence, all these things, about the nature of the institutions of medicine. I mean, they're telling a very unflattering narrative about mainstream medicine creating all of these false narratives and false dichotomies.

So, I don't think we can bury our head in the sand and just ignore it. I think that we need to engage. And I think there's a lot of people out there who are trying to engage, but I see it mostly on an individual level and not on an institutional level. I'm just starting to see some movement where they recognize, Yeah, we're living in the world with social media and non-traditional ways of communicating, and we have to incorporate this or we're going to become a fossil. We're going to be rendered irrelevant if we don't get with the times.

Wilson: Well, Dr. Steven Novella, thank you for engaging with us today and hopefully when that endowed chair for the public ...

Novella: [laughter]

Wilson: [laughter] Public education and sciences here at Yale, you can be the first chair.

Novella: I wasn't making a point, but yeah, I won't say no, yeah.

Wilson: All right.

Novella: Okay, thank you very much.

Wilson: Thank you.

F. Perry Wilson, MD, MSCE, is an assistant professor of medicine at the Yale School of Medicine. He earned his BA from Harvard University, graduating with honors with a degree in biochemistry. He then attended Columbia College of Physicians and Surgeons in New York City. From there he moved to Philadelphia to complete his internal medicine residency and nephrology fellowship at the Hospital of the University of Pennsylvania. During his post graduate years, he also obtained a Master of Science in Clinical Epidemiology from the University of Pennsylvania. He is an accomplished author of many scientific articles and holds several NIH grants. He is a MedPage Today reviewer, and in addition to his video analyses, he authors a blog, The Methods Man. You can follow @methodsmanmd on Twitter.

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